CHAPTER 20. Cultural awareness
nurses working with Indigenous Australian people
Isabelle Ellis, Christine Davey and Vicki Bradford
LEARNING OBJECTIVES
• outline the cultural diversity of Australia and identify where Indigenous people live
• recognise the effect of racism and social class on the health of Indigenous people
• differentiate between the terms cultural awareness, cultural safety and cultural competence
• assess the healthcare environment through the lens of cultural competence, and
• develop a plan to increase personal cultural competence, particularly in relation to working with Indigenous people.
INTRODUCTION
Aboriginal and Torres Strait Islander culture is said to be the oldest living culture in the world, spanning more than 40,000 years. Prior to colonisation, there were more than 200 language groups and a higher number of dialects (Aboriginal and Torres Strait Islander Commission 1998:8).
Since colonisation, Australia has developed into a multicultural society with 23.8% of its population born overseas, with 43% of those from just four countries: the United Kingdom, New Zealand, Italy and Vietnam (Australian Bureau of Statistics 2005b). Prior to colonisation the population of Australia was predominantly Aboriginal and Torres Strait Islander peoples; however, there have been many claims that trading was strong between Aboriginal and Torres Strait Islander people and the neighbouring countries. This has changed dramatically since colonisation, with the population changed to being predominantly Anglo-Celtic by 1900. Aboriginal and Torres Strait Islander people make up 2.5% of the population (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008:xxi), Anglo-Celtic 74%, other European 19%, and Asian 4.5% (Australian Bureau of Statistics 2005a). So although we consider ourselves multicultural, we are predominantly from an English-speaking coloniser background.
Australia as a nation has attained a degree of longevity, which is used as an indicator of a robust and effective health system for all groups except Indigenous Australians. The difference in life expectancy between Indigenous and non-Indigenous people is a stark reminder that there is a need for urgent action to ‘close the gap’ (Aboriginal and Torres Strait Islander Social Justice Commissioner 2005) and nurses, wherever they work, have a role to play.
In this chapter, we will explore some of the issues involved in working with Indigenous people as consumers, clients, patients, families and communities. We will identify why cultural competence is as important as clinical competence to improving the health of Aboriginal and Torres Strait Islander people for whom we care. We will also touch on some of the rewards and challenges of working cross-culturally with Aboriginal and Torres Strait Islander people.
WHAT DOES IT MEAN TO BE INDIGENOUS IN AUSTRALIA?
Being an Indigenous person means that a person identifies as an Indigenous person and acknowledges their Indigenous heritage. The United Nations has rejected the need for a definition for Indigenous people; however, it endorses the notion of a description of the concept of Indigenous, particularly the one put forward by José R Martínez Cobo in his famous study on the problem of discrimination against Indigenous populations.
Indigenous communities, peoples and nations are those which, having a historical continuity with pre-invasion and pre-colonial societies … consider themselves distinct from other sectors of the societies now prevailing in those territories … They form at present non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as the basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal systems (Cobo 1983:379–382).
The Department of Aboriginal Affairs published a report in 1981 with the working definition of Aboriginal and Torres Strait Islander, which has been tested in the courts in relation to Indigenous land claims, the jurisdiction of the Royal Commission into Aboriginal Deaths in Custody and clarifying elements of the Constitution (Gardiner-Garden 2000).
An Aboriginal or Torres Strait Islander is a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which he (she) lives.
This working definition has been adopted by government departments and organisations to determine eligibility for some programs and services. Although this three-part working definition, which comprises descent, self-identification and community recognition and acceptance, is in line with the concept of Indigenous accepted by the United Nations, it has been criticised as not originating from Indigenous people. However, it should be noted that many Indigenous people prefer to be referred to as being Aboriginal or Torres Strait Islander people rather than by the term Indigenous.
The history of recognition as an Indigenous person or community has not been straightforward in Australia. Early definitions used family tree mapping as a way of defining people’s Aboriginality and alluded to notions of dilution of Aboriginality through mixing of blood with the colonisers. These definitions were regularly used by the government to develop and implement policies from 1788 to the 1960s, and led to descriptions of people as full blood, half caste or quarter caste, based mainly on the description of skin colour by those wishing to describe, exclude or implicate the Aboriginal person in question (Eckermann et al 2006). These terms are no longer used and it is inappropriate to do so; as described by Eckermann et al (2006), it is considered to be a form of scientific racism.
THE EFFECT OF CULTURE, RACE AND CLASS ON HEALTH
Stratification of society exists in all countries. In Australia, the strata are not only between rich and poor suburbs in our major cities, but also between urban and remote areas and between non-Indigenous and Indigenous Australians. Social class, according to Walter and Saggers (2007:88), is a ‘broad concept which encapsulates both objective material position and subjective understandings and incorporates the important notion of differential access to power’. Social class also relates to social mobility, which refers to an individual’s opportunity to move up or down the social class structure. This is often leveraged through access to education, employment and health services, resulting in a sustainable standard of living. The further from the major capital cities you go, the poorer you are likely to be; and being Indigenous also makes you more likely to be poor.
Social class structures are maintained or strengthened by the process of ‘othering’ (Cahoone 2003), whereby the dominant culture, structure or class maintains its hierarchy by creating a duality and then actively excluding or opposing the other. Difference is highlighted and accentuated. The classic Dr Zeus story about the Sneetches on the beaches is a wonderful example of othering; the only difference between the two groups is whether they have a star on their belly or not. The star-bellied Sneetches create and maintain their privileged position by highlighting this difference. Othering can be expressed as bullying, social exclusion and excessive vigilance by authority figures, such as when young people are followed in shops in case they shoplift. When expressed as racism, the effects on the health of individuals and communities can be profoundly negative (Larson et al 2007).
Defining racism is not easy. In his recent systematic review on self-reported racism, Paradies (2006) found that, of the 138 studies included in the review, only 34 gave a definition of racism. Paradies proposes that racism is a form of:
… oppression/privilege which exists in a dialectical relationship with antiracism … a societal system in which people are divided into races, with power unevenly distributed, or produced based on their racial classifications (Paradies 2006:68).
Interpersonal racism is experienced as emotional upset (anger, sadness or frustration)—when a person perceives that they have been treated unfairly or have been demeaned in some way on the basis of their race. It can also be experienced as physical upset (headaches, an upset stomach, tensing of the muscles or a pounding heart). The study by Larson et al (2007) that examined the experiences of 639 residents of a town, of whom 183 identified as Aboriginal, found that Aboriginal people reported that they had received 3.6 times the amount of negative racially based treatment than non-Aboriginal people. They were more than twice as likely to report their heath as fair to poor.
In line with other research (Coffin, 2007, Eades, 2000 and Paradies, 2006), the stress experienced has a negative impact on the mental and physical health of individuals. The researchers concluded that racially based negative treatment was so common in this group that 40% of Aboriginal respondents reported it. The research found no association of negative racially based treatment for gender, education or employment status, and they concluded that all Aboriginal people may equally experience perceived racism as part of daily life.
Interpersonal racism can be overt or covert. Covert racism is unintentional, with the perpetrator not being aware (Henry et al 2004), whereas overt racism is intentional and can be perpetrated in many ways, such as: commenting on the dress or smell of a person and linking those observations to race; treating people in unequal ways based on race, such as making people wait while others are attended to straight away; speaking to adults as if they are children, such as simplifying explanations and using a tone of voice that sounds scolding or patronising.
Organisations are also able to create an atmosphere of ‘othering’. When service organisations do not recognise the need for and provide culturally safe services, they can be accused of institutional racism (Henry et al 2004). Henry et al provide several examples of institutional racism within the healthcare system, such as cultural barriers, insufficient funding, and the inequities in addressing overspending (e.g. an Aboriginal Medical Service had funding cut for overspending, while a government service was given an additional $100 million to address the overspend).
Institutional racism occurs when the policies of an organisation or institution result in Aboriginal people receiving less benefit from the same policies. This can occur in intentional or non-intentional ways (e.g. when the visiting times of a hospital do not coincide with the public transport schedules, or when the policy of the hospital states only immediate family members are able to visit an inpatient (Coffin 2007)).
Where do Aboriginal and Torres Strait Islander people live?
Indigenous people make up 2.5% of the total Australian population, with 32% living in major cities, 43% in regional areas and 25% in remote areas (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008:xxi). This distribution does not match that of the non-Indigenous population. The percentage of the total population who live in very remote areas of Australia is only 1%, as classified by the Australian Standard Geographic Classification (ASGC). Of those, Indigenous people make up 45%. In contrast, 89% of non-Indigenous people live in the major capital cities and regional areas of Australia and only 3% live in remote or very remote areas. Fifty per cent of Indigenous people live in the major capital cities, 23% live in regional areas and 27% live in remote and very remote areas.
Larson’s analysis of the migration patterns and fertility trends for remote Australia point to a continuing increase in the remote Indigenous population, as a result of both a higher fertility rate and an increase in total numbers of Indigenous people due to a lower out-migration trend. This is in contrast to a higher out-migration of non-Indigenous people, which leads to increasing Indigenisation of remote Australia (Larson 2006). It has been proposed that the remote Indigenous population will increase by 22% between 2001 and 2016, and that this reflects a similar rate of growth between 1981 and 1996 (Larson 2006).
In 2006, an Aboriginal or Torres Strait Islander woman was expected to have 2.1 babies in her lifetime, while a non-Indigenous woman would have 1.8 as an average Australia wide (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008). The age of Aboriginal and Torres Strait Islander women having babies is much younger than non-Indigenous women, with the highest number of births recorded between the ages of 20 and 24 years. Aboriginal and Torres Strait Islander babies having higher incidences of low birth weight and perinatal (foetal and stillbirth) deaths (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008).
The health of Aboriginal and Torres Strait Islander people
The neverending story about Australian Indigenous people’s health is and should be alarming to all healthcare professionals. The median age for an Indigenous person at the 2006 census was 21 years of age compared to non-Indigenous people, which is 36 years of age (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008). It is well recognised that there is a fundamental flaw in the population data collection methods that measure the health of the Indigenous population, with the Australian Institute of Health and Welfare (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008:5) noting that there was an undercount of 11.5%, but this was not distributed equally within the states and territories.
The census data is reliant on people completing the form accurately. The Australian Bureau of Statistics offers support to people who may have difficulty in completing the form. There are still many Indigenous people who are suspicious about the reason for the information and how it will be used because of past government policies and practices. There is a requirement to tick the box to identify as an Indigenous person on the national census, or Aboriginality must be recorded by a health professional in many state-based registers. The Australian Bureau of Statistics and the Australian Institute of Health and Welfare both acknowledge that there are major gaps in the Indigenous data, and many reports that appear to be national only account for some of the states, often excluding the large states of Queensland and New South Wales where 69% of the Indigenous population live.
Acknowledging these methodological problems, according to the Australian Bureau of Statistics (2003) and the Australian Institute of Health and Welfare (Standing Committee on Aboriginal and Torres Strait Islander Health and Statistical Information Management Committee 2006), Aboriginal and Torres Strait Islander people were twice as likely as other Australians to report their health as fair to poor. Indigenous Australians were twice as likely to die from cardiovascular disease, and it is the major cause for Indigenous men dying 21 years younger than non-Indigenous men. In Central Australia, Aboriginal people had the highest incidence of diabetes in the world (Australian Bureau of Statistics 2003). In remote Australia, the incidence of end-stage renal failure is up to 30 times that of non-Indigenous Australians. In 2004, Indigenous patients accounted for 85% of all newly registered dialysis patients in the Northern Territory, 20% in Western Australia and 12% in Queensland (Australian Bureau of Statistics 2005a). The story of Indigenous health inequality does not end with chronic disease. The Western Australian Child Health Survey identified that children suffer from skin, ear and respiratory infections at a significantly higher rate than non-Aboriginal children (Zubrick et al 2004).
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